GW1-2021-02002_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
�o e U/rl ��f F�/e/ lu ,� la,WATER ZONES FROM TO DESCRIPTION
Well Contractor Name /3©ft. -).5O ft.
o�©3 t� Z7�It. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
q� FROM TO DIAMETER THICKNESS MATERIAL
Ll%h Z Z/r�C 1 R. 'O ft. in. • Z 7 /t G
Company Name 16.INNER CASING OR TUBING cothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: t� l ft. R. in.
List all applicable well construction permits(i.e.County.State, Variance,etc.)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) R ential Water Supply(single) fL ft. in.
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri tion fL O ft.
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: R• ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cif applicable)
TO
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tL ft MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storrnwater Drainage fL fL -
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,seittrock type,grain sin etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) p R. _?O It.
4.Date Well(s)Completed:
5, S :30 ft. /a3 ft. Sq V
fL ft.
5.Well Location: (� /O ft. ep ft
ft. ft.
Facility/Owner Nat Facility ID#(if applicable) _
ft. fL
.2001 6 re�z �Q• �.�(iCl rt. rr.
Ph ical Address,City,and Z 21.REMARKS
llil
County Parcel Identification No.(PIN) n .�
SeCT'On
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) r
35% All 941Y N SD B 1 r1 '7 W -5'--2/
Signature of Certified Well Contractor Date
6.Is(are)the well(s): el'manent or ❑Temporary By signing this form.I hereby certify that the ivell(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constructimr Standards and that a
7.Is this a repair to an existing well: ❑Yes or IfflVo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this jorm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supph,wells ONLk with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: SRO / (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: ' (ft.) Division of Water Quality,Information Processing Unit,
Ij xwter level is above casing,use.'+" t t 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: kle construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /D Method of test: /� 24c.For Water Suaaly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:�!7' T/17� Amount: .3 Rd;6t completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013